Range of Joint Motion Evaluation Chart

NAME OF PATIENT

CLIENT IDENTIFICATION NUMBER

INSTRUCTIONS: For each affected joint, please indicate the existing limitation of motion by drawing a line(s) on the
figures below, showing the maximum possible range of motion or by notating the chart in degrees. Provide a complete
description of all affected joints in your narrative summary. If range of motion was normal for all joints, please comment in
your narrative summary. If joints which do not appear on this chart are affected, please indicate the degree of limited
motion in your narrative.
1. Back

2. Lateral (flexion)

Extension 25O

Flexion 90O

Left 25O

Right 25O

Degrees

Degrees

Degrees

Degrees

3. Neck

4. Neck (lateral bending)

Extension 60O

Flexion 50O

Left 45O

Right 45O

Degrees

Degrees

Degrees

Degrees

5. Neck (rotation)

6. Hip (backward extension)

Left 80O

Right 80O

Left 30O

Right 30O

Degrees

Degrees

Degrees

Degrees

7. Hip (flexion)

8. Hip (adduction)
Left

Knee Flexed
O
100

Degrees

Right 20O

Degrees

Degrees

Degrees
Right

Knee Flexed
O
100

Knee Extended
O
100

Degrees

Degrees

9. Hip (abduction)

DSHS 13-585A (REV. 03/2014)

Left 20O

Knee Extended
O
100

10. Knee (flexion)

Left 40O

Right 40O

Left 150O

Right 150O

Degrees

Degrees

Degrees

Degrees

11. Shoulder (Abduction Adduction)

12. Shoulder (Flexion Extension)

Left
O
Abduction 150
Adduction 30O
Degrees

Degrees
Right
O
Abduction 150
Adduction 30O
Degrees

Degrees

13. Elbow

Left
Extension 50O
Flexion 150O
Degrees

Degrees
Right
Extension 50O
Flexion 150O
Degrees

Degrees

14. Forearm (Pronation Supination)

Left

Extension 0O

Flexion 150O

Degrees

Degrees
Right
Extension 0O
Flexion 150O
Degrees

Degrees

15. Ankle

Left
O
Supination 80
Pronation 80O
Degrees

Degrees
Right

Pronation 80O

Supination 80

Degrees

Degrees

16. Ankle (Flexion Extension)

Left

Inversion 30O

Left
Eversion 20O

Degrees

Degrees
Right
Inversion 30O
Eversion 20O
Degrees

Degrees

17. Wrist (radial, ulnar)

Plantar 40O

Dorsal 20O

Degrees

Degrees
Right

Plantar 40O

Dorsal 20O

Degrees

Degrees

18. Wrist
Left

Left
O

Radial 20

Degrees

Ulnar 30

Extension 60

Degrees

Degrees

Right

DSHS 13-585A (REV. 03/2014)

Flexion 60O
Degrees

Right

Radial 20O

Ulnar 30O

Degrees

Degrees

19. Thumb (MP Joint)

DATE OF EXAMINATION

Extension 60O

Flexion 60O

Degrees

Degrees

20. Thumb (IP Joint)

Left
Flexion 60O

Right
Flexion 60O

Left
Flexion 80O

Right
Flexion 80O

Degrees

Degrees

Degrees

Degrees

EXAMINING PHYSICIANS SIGNATURE

DATE OF REPORT